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Pharmacy and Therapeutic Committees

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Drug and Therapeutic or Pharmacy and Therapeutic Committees ... Staff from medicine, surgery, pharmacy, nursing, quality management, hospital ... – PowerPoint PPT presentation

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Title: Pharmacy and Therapeutic Committees


1
Pharmacy and Therapeutic Committees
  • January 2002

2
Drug and Therapeutic or Pharmacy and Therapeutic
Committees
  • Around for a long time, various functions in
    developed countries
  • Hardly exist or function effectively in
    developing countries
  • NDPs support PTCs but in practice often meetings
    become drug shortage confrontations

3
Why interest in PTCs
  • Almost complete absence of data on improving drug
    use in hospitals in developing countries
  • Cost and quality conflicts increasing everywhere
  • Australian models seem useful
  • Recognition that quality of care determines
    willingness to pay

4
Justification for PTCs
  • Cost control
  • As technology develops, populations transform
    AIDS affects health services, pressures mount to
    control costs while maintaining services
  • Quality of Care
  • Quality is determined by more than structures and
    resources. Need processes and people to produce
    outputs
  • Efficiency
  • As health systems become more complex, efficiency
    requires effective communication and collaboration

5
Essential Function of PTCs
  • Meeting ground between clinicians, pharmacists
    and financial managers to negotiate the balance
    between cost and quality.
  • The pharmacist often has to play the role of an
    expert referee!

6
Membership
  • Staff from medicine, surgery, pharmacy, nursing,
    quality management, hospital administration,
    information systems, and infection control. In
    Australia community members!
  • The number of members range from eight to twelve
    in the United States, with Australia averaging
    nine members.
  • The chairperson is chosen usually from clinical
    members while secretary a pharmacist.

7
Meetings Frequency and Duration
  • Most committees meet monthly,
  • usually for 60 to 90 minutes

8
Terms of Reference
  • Includes
  • Selection
  • Standard Treatment Guidelines
  • Drug Utilization Review
  • Production of Drug bulletin
  • Providing objective information including DICs
  • Adverse Drug Reactions
  • Medication errors
  • Control of Drug Reps
  • ????

9
Functioning in Practice
  • Selection
  • Hospital Formulary or Hospital drug lists e.g.
    Emergency, Surgical, Medical, Pediatrics etc
  • Review of Applications for additions, deletions,
    buying out, special requests, ABC Analysis
  • Defining drug priority VEN analysis
  • Producing and Reviewing STGs
  • Disease or Drug based Examples Cerebral Malaria,
    OP hypertension OR blood, ciprofloxacin or
    ceftriaxone
  • Defining levels of use
  • Specialist only, counter signatures,
  • Distribution controls

10
Functioning in Practice (2)
  • Educational Activities
  • Printed Materials
  • Large Group teaching
  • Small group teaching
  • Individual detailing
  • Teaching Nurses, medical students, new appointees
  • Opinion leaders

11
Drug Utilization Review / Evaluation
  • Effective but not that frequently done
  • Steps
  • Problem Identification (Condition or drug)
  • Define criteria
  • Measure performance
  • Compare performance with criteria
  • Feedback results

12
Other Functions
  • ADR Monitoring
  • Medication Errors

13
Adverse Drug Reaction Reporting
14
Adverse Drug Reaction Assessment
15
Adverse Drug Reaction Assessment
16
Other functions (2)
  • Controlling drug reps (Achieving the impossible!)
  • Appointments
  • Prior review of materials
  • Equal time for presentations
  • Patients have priority!

17
Evaluation of Interventions
  • Structural and Process evaluation needed annually
  • Outcome evaluation of interventions
  • Best method is time series ideally with a control
    hospital. Need at least 6 points before and at
    least 6 points after intervention. Better to have
    8 or 12 pre and post time points

18
Data Sources for Monitoring Evaluation
  • Drug Stock records
  • Prescribing records
  • Dispensing records
  • Case notes
  • Registers of Expensive drugs
  • Financial Records

19
Budgeting for PTC Activities
  • Consider
  • Staff time costs
  • Meeting costs (Food, parking, duplication)
  • DUR data collection costs
  • Intervention costs
  • Reporting costs

20
Difficult PTC Issues
  • Conflict of Interest
  • Lack of adherence to PTC decisions
  • Role of Pharmaco-economics in decision making
  • Lack of evidence based assessment in selecting
    drugs for formulary
  • Appeal mechanisms and transparency

21
What makes a successful PTC?
  • Chairman
  • Members
  • Quality and responsiveness of technical support
  • Attendance and involvement at meetings
  • Members carry decisions back to their departments

22
Why is it so difficult to get these committees to
function effectively?
  • Personal View
  • Clinicians, pharmacists and financial managers
    have different world views.
  • For progress each group need to understand and
    respect the others world view

23
Importance of PTCs
  • With technology development, changing patterns of
    disease and financial limits, critical that these
    committees function effectively
  • Each committee will need to determine their own
    priorities, work plans and systems
  • Without these committees decisions will be taken
    without regard for quality of care or cost
    efficacy of treatment

24
Boston Area PT Survey
  • Determine the positive and negative
    characteristics of PT Committees
  • What makes a PT Committee successful?
  • Application in developing countries

25
Methods
  • Created Survey Instrument to gain qualitative and
    quantitative data
  • Piloted Instrument Internally. Gave interviewers
    practice to be sure they understood questions.
    Also practiced responding to some answers and
    styles (reluctance to share, time constraints,
    etc)

26
Methods
  • AHA code chart to identify hospitals
  • Inclusion Criteria 40 mile radius Boston
  • Exclusion Criteria

27
Methods
  • 47 hospitals randomly selected using Metastat
    2.01
  • 2 hospitals merged
  • 8 hospitals too far away to visit
  • 37 hospitals sent invitation letter (BU SPH
    letterhead, Richard and Brenda authors)
  • 27 hospitals telephone follow-up by Brenda

28
Methods
  • Of 27 hospitals phone follow-up
  • 4 refused to participate
  • (assumed that refusal to participate more likely
    with lower performing PT C)
  • 5 hospitals could not find mutual meeting times
  • Final sample size14 hospitals

29
Methods
  • Directors of Pharmacy interviewed
  • (usually serve as secretary of PT)
  • Occurred over 6 weeks in early 1998
  • Predetermined questions/survey
  • 2 Interviewers per site (1 asks, 1 records)
  • 60-90 minute interviews

30
Results Structure Organization, Evaluation
  • 9 of 14 Mission Statement
  • plan
  • 9 of 14 evaluated by JCAHO (every 3 years)
  • 3 of 14 have inhouse evaluation

31
Results Meetings
  • All meet regularly
  • 9 of 14 meet monthly
  • most have fixed meeting times (first Thursday,
    etc)
  • 1-1.5 hour meetings
  • early morning (730am) -convenience or midday
    (lunch providedincreases attendance)the 1
    hospital that did not serve lunch had lowest
    attendance rate

32
Results Membership
  • Common Medicine, Surgery, Nursing, Pharmacy,
    Hospital Administration, Quality Assurance /
    Infection Control
  • Others Nutrition, Lab staff
  • None had IT..but available for consult
  • None had ethicist or community representation and
    not available for consult

33
Results Attendance
  • Range 50-100
  • MDs and Surgeons lowest attendance
  • Medicine 67, Surgery 58, Pharmacy 96, Nursing
    90, QA 89, Administration 78, Infection
    Control 87
  • Nutrition 82, Laboratory 80
  • Other Not open to all staffrequire invitation
    to attend
  • No Drug Reps

34
Results Incentives
  • 13 of 14 offer food
  • Power and Prestige
  • None pay extra money

35
Results Minutes
  • All record minutes
  • 1/2 send minutes to medical executive committee
  • none distribute to med/surg staff or nursing
    staffhave access of they ask
  • some send to pharmacy

36
Results Budget and HR
  • 1 of 14 has money allocated to PT
  • 3 of 14 give staff time to prepare for meeting

37
Functioning
  • All review ADRs..some use subcommittees
  • 13 of 14 review medical errors
  • All provide educational materials to
    staff..memos, newsletters, computers
  • 11 of 14 endorse objective detailing-providing
    information proactively (rounds) or reactively
    (phone after order written)

38
Functioning
  • All conduct DUR/DUE (JCAHO requirement)
  • Results not effectively distributed to staff
  • 10 of 14 have presentations to MDs on improving
    drug use, usually in a specific area

39
Functioning
  • Adding Medications to Formulary Not added 0-60
    time (usually 10-25)..usually handled
    informally and never make it to meetings
  • 2-30 drugs per year added
  • 0-24 drugs removed from formulary
  • 12 of 14 more added than removed

40
Functioning
  • Therapeutic Guidelines never denied- generated
    by pharmacy
  • seen as lower priority
  • Drug-Use Guidelinesnever denied
  • 1-30 per year (3-6)

41
Functioning
  • All base decision to add on clinical safety and
    efficacy
  • 13 of 14 use economic analysis..teaching
    hospitals more inclined to use p-economics
  • 3 of 14 look only at cost of drug

42
Functioning
  • 10 of 14 had guidelines on how to submit request
    to add
  • Any attending MD can make request
  • Some allow pharmacy and nursing to request, some
    require chief signature,
  • Drug reps go through MDs to get their drugs added

43
Functioning
  • 1/2 Peer review
  • Not formal or outlined
  • Pharmacy does lit search and grunt work
  • 11 of 14 oversee nonformulary drug use
  • 5 issue a report of use by MD

44
Drug Promotion
  • Problem in all pharmacies
  • 9 of 14 have policies on drug promotion
  • Policies deal with access, involvement with
    MDs, samples
  • Enforced by director of pharmacy (sign in and out)

45
Effectiveness
  • Characteristics associated with highly
    functioning committees
  • personality of chairman integrity, respected,
    focus on efficacy and cost
  • commitment of members willing to attend,
    energetic, forward thinking

46
Effectiveness
  • Characteristics associated with low-functioning
    PT Committees
  • Promotional Activities of Drug Industry no
    medical education, marketing data-not clinical
    data
  • Poor Attendance
  • Interpersonal Dynamics of Members hidden
    agendas, proprietary interests, turf

47
Discussion
  • All had mission statements, but FEW were able to
    provide it
  • Few have strategic plans-function routinely
    instead of filling hospitals needs
  • No real evaluation process
  • Minutes recorded but not distributed
  • Workload not spread out

48
Discussion
  • DUE/DUR not a priorityconflict with published
    data on importance of DUR
  • More drugs added than removed
  • P-economics not applied, cost comparison and
    cost-utilization used
  • Many lack peer review
  • Many do not report nonform use

49
Discussion
  • Some have no drug promotion policy
  • Policies are inadequate

50
Not reported to Increase Effectiveness
  • Lack of training in p-epi, p-economics, lit
    review, negotiation skills

51
recommendations
  • Require a written mission statement that is
    dynamic
  • Require strategic plan that is reviewed by
    medical executive committee
  • Create an appeal process
  • Provide incentives meeting time and food
  • Record AND DISTRIBUTE minutes

52
recommendations
  • 0.5 FTE including 1 RPH and director of pharmacy
    dedicated to PT activity
  • Active DUR/DUE
  • Make decisions to add on therapeutic guidelines
    and remove drugs regularly
  • Peer review
  • Report NF use

53
recommendations
  • Explicit policy on drug promotion enforcement,
    WHO ethical guidelines on drug promotion
  • Find the right chairman
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